Predictive factors of anxiety and depression in COVID‐19 survivors: A cross‐sectional study

Abstract Background Depression and anxiety are among the most critically recognized psychological complication of the COVID‐19 pandemic. Aim This study aimed to examine the two predictors among COVID‐19 survivors in Ahvaz, Iran, in 2022. Methodology Using a descriptive‐analytical design, 347 COVID‐19 survivors referred to hospitals in Ahvaz were meticulously examined. The database of the COVID‐19 registration system contained primary information about the samples. For data collection, questionnaires, including the Beck Anxiety and Depression Inventory and a demographic questionnaire, were utilized. Results The results revealed a significant relationship between anxiety score and family size (p = 0.019), education level (p < 0.001), occupation (p = 0.015), household income status (p = 0.017), disease history (p = 0.017), ethnicity (p < 0.001), disease severity (p < 0.001), and quarantine period (p < 0.001). Furthermore, a significant correlation was observed between the average depression score and gender (p = 0.023), number of family households (p = 0.009), level of education (p < 0.001), occupation (p < 0.001), household income (p < 0.001), disease severity (p < 0.001), disease history (p < 0.001), and quarantine period (p < 0.001). Moreover, linear regression analysis indicated only a significant relationship between depression scores and the quarantine period variable (p < 0.001), among others. The simultaneous examination of all variables on depression disorder highlighted a meaningful relationship between depression score and disease history (p = 0.013), occupation (p = 0.002), household income status (p = 0.002), and family size (p = 0.039). Conclusions This study revealed a significant relationship between certain demographic variables, such as quarantine period, disease history, employment status, household income status, and the number of family households, and an increase in the average depression and anxiety score.

Covid survivors detained in the hospitals affiliated with Ahvaz Jundishapur University of Medical Sciences in the first half of 2021 constitute the participants in the study.The hospitals' databases of the COVID-19 registration system including demographic data, admission data, the treatment procedures of the disease, signs, and symptoms (such as fever, cough, etc.), computerized tomography (CT)-scans, polymerase chain reaction (PCR) tests, vital signs, pregnancy and background diseases, intensive care units (ICU) hospitalization, tracheal intubation, and the discharge status (discharge, dispatch, or death) of patients and suspected Covid patients were used in the study.Baloch et al. 12 were modeled considering the number of samples to be statistically significant with 95% confidence and 80% test power if each correlation coefficient between variables is 0.15 or more.The following formulas were then used to calculate the size of the sample, and accordingly, 347 COVID survivors were selected from the list using a systematic random sampling method.A reserve list of 70 people was also made ready at hand according to the 20% drop rate of the sample size to be involved based on the entry criteria if the selected participants withdraw from the study.According to the sample size (347 people), the K value was calculated as k = =4 7 / 6 7≈ 47 16542 347 , and a random number between 1 and 47 were selected (number 39 was selected randomly).The value of k = 47 was added to the number 39, and this process continued until the completion of 347 samples.
Inclusion criteria consisted of the 18-65 age range, the ability to speak, read and write in Persian, access to a smartphone and having In measuring the reliability of the Beck Depression Inventory, a high-level analysis of various attempts for internal consistency determination illustrated that the obtained coefficients ranged from 0.73 to 0.92 with an average of 0.86. 22The reliability of this study's questionnaire in a sample of 94 participants in Iran was as follows: Cronbach's ⍺ coefficient of 0.91%, the correlation coefficient between the two halves of the test of 0.89%, and the retest coefficient of 0.94%. 23arifi Daramadi and Ghasemi Davari estimated the reliability and validity of the Beck Depression Inventory as 0.85 and 0.76, respectively. 24Also, the correlation of the Beck Depression Inventory with its first edition was 0.93. 25e convergent validity of the Beck Depression Inventory was obtained through its simultaneous implementation with Beck Hopelessness Scale, Suicidal Thoughts Scale, and Beck Anxiety Inventory as 0.68, 0.37, and 0.60, respectively. 26Also, the correlation coefficient of the Beck Depression Inventory with the Hamilton psychiatric rating scale for depression is 0.73 and with the MMPI (Minnesota Multiphasic Personality Inventory) is 0.74. 24Beck Anxiety Inventory bears high validity according to the investigations of validity and reliability.The internal consistency coefficient of the anxiety scale inventory (alpha coefficient) and its reliability are reported as 0.92 and 0.75 with a 1-week interval.Also, the anxiety scale inventory was obtained with a high internal consistency with correlation values in the range of 30-70.A high level of correlation (0.75) was obtained through the implementation of this test on 83 patients with a 1-week interval for the retest. 27The correlation for depression inventory results was measured with Hamilton Rating Scale for Depression and Hamilton Anxiety Rating Scale as 0.51 and 0.25, respectively.In addition, the correlation between depression inventory results with depression inventory was 0.48. 28A B L E 1 Descriptive analysis of participants' demographic characteristics (n = 347).were quarantined at home when they were infected with COVID, and the last time of quarantine was reported between 1 and 7 days (Table 1).
Analysis of the frequency of anxiety among participants by gender indicates that 11 (33.1%) and 74 (21.3%) participants have no or the minimum and the most severe depression, respectively.In addition, the results reveal that the anxiety degree (mild to severe) is more in women than in men (Table 2).Meanwhile, the frequency distribution of the depression degree among the participants by gender demonstrates that 247 participants (71.2%) have the lowest depression degree and 21 participants (6.1%) have a severe depression degree, among which the depression degree (mild to severe) is reported more in women than in men (Table 2).
Considering   3).The analysis also reveals that the average score of anxiety and depression is higher in participants with family size four or more than those living in a family of 1-3 households.Regarding the education level, the highest level of anxiety score is observed in participants with lower than high school education.Moreover, Arabs experience higher anxiety and depression compared with the other ethnic groups in the study.
Considering the relationship between occupation and anxiety score, it is observed that the housewife group and the employee/ nonemployee group experience the highest and the lowest average anxiety and depression, respectively.Also, the highest and the lowest average anxiety scores are observed for the participants without and with sufficient income, respectively.Furthermore, the average anxiety score is higher in participants with a disease history than in participants without it.Finally, the average anxiety score of participants hospitalized is higher than that of the participants quarantined at home.In the same vein, the lowest average anxiety score is reported for the participants quarantined at home between 1 and 7 days.Multiple linear regression was used for the simultaneous examination of the variables on anxiety and depression disorders.The results of multiple linear regression demonstrate that the relationship between anxiety scores is significant only with the quarantine period variable (p < 0.001).In this regard, the regression coefficient for the anxiety score of the participants quarantined at home is equal to −7.373, with a standard error of 1.609.In other words, the average anxiety score is 7.373 points less in the quarantined participants in comparison with those who were not quarantined (i.e., the hospitalized participants), which is statistically significant (p < 0.001) (Table 4).Furthermore, in the simultaneous analyses of all variables on depression disorder, it was revealed that among the significant variables from the previous stage, there is a significant relationship between the depression score and other disease history (p = 0.013), occupation (p = 0.002), household income (p = 0.002), and family size (p = 0.039) (Table 4).
T A B L E 3 Analysis of anxiety and depression scores by demographic variables.Psychological complications are one of the most severe consequences of the COVID-19 pandemic, alongside social and economic damages and high mortality.In addition to increased depression, stress, anxiety, and fear among various social groups, it may also result in unhealthy conditions, chronic diseases, and risky behaviors, such as increased smoking, drug abuse, alcohol consumption, aggressive behaviors, and suicidal thoughts. 14The psychological effects of the virus will be felt long after the pandemic, and the confrontation of the mind and psyche with this phenomenon will continue to influence the mentalities, thoughts, emotions, and life processes of the affected individuals, families, and society for years. 30nsequently, the present study aimed to investigate the demographic and background variables associated with anxiety and depression in COVID-19 survivors.
The results generally reveal a significant relationship between quarantine period and anxiety, while a significant relationship exists between depression and disease history, occupation, household income status, and family size.In this regard, the regression coefficient indicates that the average anxiety score of participants quarantined at home is 7.373 points lower than that of participants hospitalized.After surviving the pandemic, patients quarantined at home despite fears of disease transmission to other family households are less likely to develop anxiety-related psychological disorders.Nonetheless, it is demonstrated that there is a positive correlation between the quarantine period and the average anxiety and depression scores.Thus, it emphasizes the significance of social isolation caused by quarantine concerning the increased likelihood of anxiety and depressive disorders, as suggested by other studies that anxiety and depression symptoms can remain after recovery from COVID-19. 31,32On the other hand, regression coefficient results indicate that the average depression score is lower among patients with sufficient income levels than among patients who consider their household income somewhat or entirely insufficient.The average depression score is higher in families with more than four members than in families with one to three.In addition, examining the relationship between demographic variables and average depression score reveals that the average depression score of participants with a disease history is 3.554% higher than that of participants without a disease history.In addition, the average anxiety score among employees and nonemployees is 4.109 points lower than that of homemakers and other groups.
Studies indicate that COVID-19 has caused psychological disorders and mental health issues, such as anxiety and depression, in various societies. 11For example, a longitudinal study revealed that more than half of hospitalized COVID-19 patients experienced COVID-19 syndrome and disease symptoms between 3 and 6 months after discharge. 33Another study investigated the long-term symptoms of depression and anxiety in Spanish patients who survived COVID-19; in the study, 1969 men and women hospitalized for 6-8 months were examined.The prevalence of anxiety and depression in COVID-19 survivors was 16.2% and 19.7%, respectively. 34Consistent with these studies, the present study found that 66.8% of COVID-19 survivors suffered from mild to severe anxiety disorder after recovery.
They observed a significant trend of psychological disorders such as depression, anxiety, and stress increasing over time.In addition, they found a significant correlation between anxiety level and education level, occupation, and age, as well as between depression level and occupation. 13e present study's linear regression analysis reveals a significant correlation between ethnicity, quarantine period, and anxiety score.
In addition, there is a significant correlation between the depression score and disease history, occupation, household income, and the T A B L E 4 Linear regression analysis to examine the relationship between anxiety and depression.number of family households.Considering employment status, the results indicate that the unemployed, university students, and retirees have higher depression scores than the other participants.
Consequently, the effect of social isolation caused by unemployment and insufficient income during the pandemic is emphasized.Contrary to Othman and Baloch et al., our findings suggest an inverse relationship between the average anxiety and depression scores and education level, meaning that the higher the education level, the lower the average anxiety and depression scores. 12,35cording to a study conducted in the southern regions of Sistan and Baluchistan (Iran), gender, employment, and insurance coverage variables have a statistically significant relationship with anxiety and depression caused by the pandemic. 12recent study revealed that men score higher on average for anxiety and depression than women. 12However, the current study shows no statistically significant differences between the average anxiety scores of men and women, whereas the average depression scores of men are higher (p = 0.023).Some epidemiological studies have reported that women are more likely to suffer from depressive disorders than men.However, the present study's findings contradict these findings. 36ya Puran et al. examined the prevalence of depression, anxiety, and suicidal ideation among nurses during the COVID-19 outbreak and their relationship to demographic variables.They observed that depression is more prevalent among female nurses than male nurses. 14In a study conducted in Wuhan, China, on the correlation between gender and stress and anxiety disorders during the COVID-19 pandemic, female nurses exhibited more stress and anxiety symptoms when working with COVID-19 patients. 11In another study on the influence of sociodemographic factors on anxiety and depression levels among university students and faculty households at Jouf University during the pandemic, it was observed that women suffer from moderate anxiety and depression more than men. 37study examining the occurrence and outcomes of psychological interventions during the pandemic found that prolonged quarantine duration, concern about the spread of the disease to others, frustration and fatigue, and a lack of information about the disease and its symptoms can contribute to the development of psychological disorders. 15Another study observed that the education level of nurses influences their depression rate.The marital status and workplace of nurses also play a significant role in anxiety rates.
Findings indicated that B.Sc. degree holders had more suicidal thoughts than M.Sc.holders.In addition, single nurses had higher anxiety and suicidal ideation rates than their married counterparts.
Finally, it was observed that emergency department, CCU, and ICU nurses had the highest average anxiety rate. 14However, according to the results of the current study, there is no correlation between the average anxiety and depression scores and marital status and age variables.An analysis of the results revealed that the average anxiety and depression scores are higher among divorced or widowed individuals.Similarly, Ramandi et al. found a higher incidence of depression and anxiety among widows. 38 addition, anxiety and depression are more prevalent among those aged 34-47 and 48 years and older, respectively.Similarly, Abadi et al. found that the rate of depression is higher among those aged 31-49, which may be due to a lack of energy, a busy lifestyle, and diminished social interaction. 39However, a separate study found that the likelihood of suffering from an anxiety disorder increases with age between 30 and 39. 40 According to a study on the relationship between demographic variables and the level of anxiety and stress among students and faculty households of Jouf University during the COVID-19 pandemic using the Beck Inventory, Ganji et al.
found that ethnicity and age are among the most influential factors in anxiety and depression levels, such that the average anxiety and depression rates were higher among individuals aged 20-30 and of Saudi Arabian nationality. 37The present study found a significant correlation between ethnicity and the average anxiety rate but none between ethnicity and the average depression rate.behaviors must be adopted or maintained through effective health promotion strategies to reduce the acute and chronic increase in psychological distress.Finally, public health messages activating selfmanagement cognitive resources, processes, and psychological capital can foster health-protective behaviors.In addition, this study revealed a significant correlation between certain demographic variables, such as quarantine period, disease history, employment status, household income status, and the number of family households, and an increase in the average depression and anxiety score.
Patients and survivors of COVID-19 must therefore be screened for and treated for psychological disorders like depression and anxiety. To

2
Use was made of a random number generation software in the selection procedure from number 1 to 16,542 (the number of people registered in the COVID-19 databank) in proportionate to the sample size for conducting a quantitative study.In so doing, a comprehensive list of patient files in the databank of the COVID-19 registration system of Jundishapur University of Medical Sciences was prepared.The files were then numbered from 1 to 16542.
informed consent.Exclusion criteria consisted of suffering or history of psychological disorders, taking psychiatric drugs, unwillingness or refusal to participate in the study, and incomplete completion of questionnaires.All 347 selected people were contacted by phone and given explanations about the study objectives.The links to Beck Anxiety and Depression Inventories, demographics, and background questionnaires were sent to the willing participants through social media platforms.The scores obtained through the anxiety and depression inventories were used to categorize the participants into three groups, namely mild, moderate, and severe.Participants in the severe category were referred to a psychiatrist for treatment.A researcher-made demographic questionnaire including 12 demographic and clinical questions regarding the participants' particulars (age, gender, marital status, education level, occupation, household income status, ethnicity, place of residence, family size, quarantine status, other disease history, and COVID-19 severity) was distributed at an early stage of data collection.Participants were then asked to fill out the Beck anxiety assessment inventory which includes 21 questions-each question covering four possible choices ranging from never, mild, moderate, to severe.The four choices in each question of the Beck Anxiety Inventory are scored from 0 to 3. Each part of the test describes one of the common symptoms of anxiety (mental, physical, and fear symptoms), and the total score ranges from 0 to 63.The anxiety degree based on Beck Anxiety Inventory is determined in ranges 0-7 as none or minimal, 8-15 as mild, 16-25 as moderate, and 26-63 as severe.Much in the same vein, the Beck Depression Inventory includes 21 items for each of which four possible choices are provided to indicate the participant's feelings and behavior.The following scores are used to indicate the depression severity level: 0-13 (none or minimal depression), 14-19 (mild depression), 20-28 (moderate depression), and 29-63 (severe depression).

4. 1 |
Study limitationsOn the other hand, the current study has several drawbacks.First, data reliability is diminished due to self-reporting and online questionnaire completion.Due to the lengthy number of questions, participants may not have been in a good mood while completing the questionnaires.Thirdly, this study was restricted to samples that were able to use the internet and participate in the study online, as well as those who have survived COVID-19 in the hospitals of Ahvaz and whose records were available in the COVID-19 registration system database.These particulars ultimately limit the generalizability of the findings.Conducting investigations on a larger scale with a larger sample size is recommended in future studies.In addition to investigating the demographic characteristics, the relationship between anxiety and depression disorders, coping styles, and environmental factors will be examined.In addition, future studies can improve the generalizability of the samples by including patients from other regions of the country.5 | CONCLUSIONThe COVID-19 pandemic has caused physical health concerns and significantly increased the incidence of adverse psychological complications, such as depression and anxiety, in infected individuals, with some survivors experiencing long-term effects.Potentially, psychological capital interventions should be tailored to at-risk populations with benefits for current and upcoming pandemics and health crises.In these unprecedented times, positive health-related SOHRABIVAFA ET AL.|of 9

Table 1 .
29is study used the Kolmogorov-Smirnov test to investigate the normality of data.In the case of data normality, parametric tests of one-way analysis of variance, t test, and in the case of nonnormality, the nonparametric tests of Kruskal-Wallis and Mann-Whitney were used.Multiple linear regression was used to simultaneously examine all variables on anxiety and depression,29and all the statistical tests were performed by SPSS (version 24).Background disease was observed among 274 participants (79%).According to the participants' report, 228 participants (66%)

Table 3
scores shows that the highest and lowest average anxiety score belongs to the household group(19.41±14.43)andemployee/nonemployeeoccupational group (14.44 ± 12.07), respectively.The highest(18.32 ± 13.20) and lowest (62 ± 11.44) average anxiety scores are observed for participants without and with sufficient income for subsistence, respectively.The average anxiety score is higher in participants with other disease histories(19.39±14.37)than in participants without another disease history (15.17 ± 12.70).
Descriptive analysis of anxiety and depression in participants by gender.

Table 3
this end, it is suggested that vulnerable groups receive timely and appropriate psychological interventions through counseling and psychological services and increased financial and psychological support.